MEDICARE: AMY L MACK LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	090752	NY
2	1041C0700X	Clinical Social Worker	1843	NH

General Provider Information

NPI Number	:	1104241066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY L MACK LICSW

Provider Business Mailing Address
First Line	:	5708 S BAY RD
Second Line	:
City	:	CICERO
State	:	NY
Zip	:	13039-8652
Country	:	US
Telephone Number	:	315-897-5699
Fax Number	:	315-302-9599

Provider Business Practice Location Address
First Line	:	5708 S BAY RD
Second Line	:
City	:	CICERO
State	:	NY
Zip	:	13039-8652
Country	:	US
Telephone Number	:	315-897-5699
Fax Number	:	315-302-9599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2014
Last Update Date	:	03/04/2026

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